Request For Enrollment In Supplementary Medical Insurance

REQUEST FOR ENROLLMENT IN SUPPLEMENTARY MEDICAL INSURANCE

OMB: 0960-0092

IC ID: 114610

Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details

View Information Collection (IC)

REQUEST FOR ENROLLMENT IN SUPPLEMENTARY MEDICAL INSURANCE
 
No Migrated
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form SSA-4040 No No


    

90,000 0
   
Individuals or Households
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 90,000 0 0 0 0 90,000
Annual IC Time Burden (Hours) 9,000 0 0 0 0 9,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
 
 
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

© 2024 OMB.report | Privacy Policy